Development of systems of care for ST-elevation myocardial infarction patients: the non-percutaneous coronary intervention-capable (ST-elevation myocardial infarction referral) hospital perspective.

Developers of systems to improve access to primary percutaneous intervention (PCI) must recognize that most ST-elevation myocardial infarction (STEMI) patients present to hospitals that do not have PCI capability. Indeed, only 25% of US hospitals are currently capable of delivering this intervention.1 These non–PCI-capable institutions are often located in rural areas and face real challenges related to distance from PCI centers. In addition, these institutions face significant financial challenges2 in pursuing any of the 3 potential strategies to increase timely access to primary PCI. These 3 strategies include the following3: (1) hospitals currently without PCI capability can develop primary PCI services without cardiac surgery on-site (SOS); (2) non–PCIcapable facilities can rapidly diagnose and transfer STEMI patients to primary PCI-capable hospitals and thereby serve as STEMI referral hospitals; or (3) communities can develop systems that bypass non–PCI-capable hospitals. Each of these strategies is addressed in this article. For each, we review the current status, the ideal system, gaps in and barriers to development of the ideal system, and recommendations. Develop Primary PCI Capability Without Cardiac SOS Current Status Early observational studies from single institutions demonstrated potential efficacy and safety of primary PCI without SOS. In the Myocardial Infarction, Triage and Intervention (MITI) trial, 233 of 441 primary PCIs were performed at hospitals without SOS. Emergency cardiac surgery was rare (1.4% of patients), and its presence or absence did not affect survival after myocardial infarction.4 In another observational study, among 334 patients undergoing primary PCI at a hospital without SOS, there were no deaths, and no patient required emergency coronary artery bypass grafting (CABG).5 In a nonrandomized comparison of patients undergoing primary PCI at hospitals without SOS with those undergoing primary PCI after transfer to a tertiary hospital, there was no difference in 30-day or 1-year mortality, although time to reperfusion was significantly shorter, and restoration of Thrombolysis In Myocardial Infarction (TIMI) 3 flow occurred significantly more often in patients undergoing primary PCI without transfer to a tertiary site.6 Only 2 patients (0.4%) required emergency CABG. In a randomized controlled trial in community hospitals, STEMI patients treated with primary PCI had a 42% lower incidence of the composite end point of death, recurrent infarction, or stroke at 6 months (which was driven by a reduced rate of reinfarction), and the median length of stay was reduced by 1.5 days compared with patients treated with accelerated tissue plasminogen activator.7 No patient required emergency CABG for PCI-related complications. In another study,8 investigators used the National Registry of Myocardial Infarction (NRMI) database to compare qual-